Endometrial cancer patients understanding and interest in weight loss surgery.

OBJECTIVE: Obesity is a risk factor for endometrial hyperplasia (EH), endometrial intraepithelial neoplasia (EIN), and early type 1 endometrial cancer (EC) in 70%-90% of patients and is often a significant contributor to overall morbidity and mortality due to comorbidities. In 2011, bariatric surgery (BS) with lifestyle modification was identified as an intervention for reduction in overall mortality as well as risk for gynecologic cancers (Tsui et al., 2021). Our aim was to assess awareness of obesity as a risk factor and understanding of BS in an underinsured obese patient population with EC or EH. METHOD: This IRB-approved survey was distributed to patients with type I EC or EH within the past 5 years and a BMI >30. Questions addressed demographics, health habits, cancer and obesity awareness, as well as benefits and concerns about undergoing BS. Information was provided about dietary requirements after BS, and then interest in BS was surveyed. RESULTS: 61.2% of surveyed patients were interested in bariatric surgery for weight loss after receiving education about the procedure. Interest in bariatric surgery was correlated with higher BMI, higher ideal and comfortable weight loss in pounds and higher estimated weight loss that could be obtained with bariatric surgery. Additionally, patients who were interested in BS had better understanding of the risks of obesity with cancer overall. CONCLUSION: Obese patients with history of EC/EIN/EH are aware of hazards associated with excess weight and understand the relationship between EC/EIN/EH diagnosis and obesity, and overall are very interested in BS as a modality to improve their health.

Botulinum toxin A versus electrogalvanic stimulation for levator ani syndrome: is one a more effective therapy?

BACKGROUND: Levator ani syndrome (LAS) is a functional disorder that can be a challenge to treat. LAS that is refractory to medical management may be treated with electrogalvanic stimulation (EGS) or Botulinum toxin A (BTX) injection. The aim of the present study was to evaluate the outcomes associated with both EGS and BTX in patients with medically refectory LAS to determine if either demonstrate a long-term benefit or whether one treatment is better than the other. METHODS: A retrospective study was performed on consecutive patients with LAS treated with BTX or EGS at our institute. Patients were identified from a prospectively maintained database. The study time frame was 6 years. RESULTS: One hundred and twenty patients [80 females, mean age 52 years (range 21-84, SD 15.8)] were treated for medically refractory LAS: 102 with BTX and 18 with EGS. With EGS, 28.6% of patients reported a complete response, 14.3% reported a partial response and 57.1% reported no response to treatment. With BTX, 35.5% of patients reported a complete response, 19.7% reported a partial response and 44.7% reported no response to treatment. There was no difference between BTX and EGS with regard to treatment response. Patients who had BTX were more likely to report a short-term benefit in treatment when compared to those patients who had EGS (p = 0.002). This difference between reported outcome to BTX and EGS treatments did not sustain in the long term (p = 0.2). CONCLUSIONS: Both BTX and EGS are to some extent effective at resolving symptoms of LAS. In the short term, BTX appears to be more effective. Neither treatment sustains its benefit in the long term.

Integration of a recent infection testing algorithm into HIV surveillance in Ireland: improving HIV knowledge to target prevention.

Recent infection testing algorithms (RITA) for HIV combine serological assays with epidemiological data to determine likely recent infections, indicators of ongoing transmission. In 2016, we integrated RITA into national HIV surveillance in Ireland to better inform HIV prevention interventions. We determined the avidity index (AI) of new HIV diagnoses and linked the results with data captured in the national infectious disease reporting system. RITA classified a diagnosis as recent based on an AI < 1.5, unless epidemiological criteria (CD4 count <200 cells/mm3; viral load <400 copies/ml; the presence of AIDS-defining illness; prior antiretroviral therapy use) indicated a potential false-recent result. Of 508 diagnoses in 2016, we linked 448 (88.1%) to an avidity test result. RITA classified 12.5% of diagnoses as recent, with the highest proportion (26.3%) amongst people who inject drugs. On multivariable logistic regression recent infection was more likely with a concurrent sexually transmitted infection (aOR 2.59; 95% CI 1.04-6.45). Data were incomplete for at least one RITA criterion in 48% of cases. The study demonstrated the feasibility of integrating RITA into routine surveillance and showed some ongoing HIV transmission. To improve the interpretation of RITA, further efforts are required to improve completeness of the required epidemiological data.

Do uterine risk factors or lymph node metastasis more significantly affect recurrence in patients with endometrioid adenocarcinoma?

OBJECTIVES: Controversy continues over the importance of lymph node (LN) status in treating and predicting recurrence in endometrial cancer. Several predictive models are available which use uterine factors to stratify risk groups. Our objective was to determine how LN status affects recurrence and survival compared to uterine factors alone. METHODS: A retrospective review was performed of patients undergoing complete surgical staging for clinical stage 1 endometrioid adenocarcinoma of the uterus. Patients were assessed based on PORTEC 1 high intermediate risk (H-IR) criteria (2 factors : age>60, grade 3, >50% DOI), GOG-99 H-IR criteria (age >70+1 factor, age 50-70+2 factors, any age +3 factors: grade 2 or 3, LVSI, >50% DOI), and PORTEC 2 criteria. Rates of nodal involvement, recurrence rates, PFS, and OS were compared. RESULTS: We identified 352 clinical stage I patients with positive LN in 24% (87). 175 patients met PORTEC 1 eligibility and 66 met H-IR criteria. Rates of LN positivity were similar among groups (18.4% vs 19.7%, p=0.83) but recurrence rates were dissimilar (7.4% vs 27.3%, p=0.0004). Only 93 met PORTEC 2 criteria for treatment with no association between LN status, recurrence, and eligibility. 188 patients met H-IR eligibility criteria for GOG-99 with LN positive and recurrence rates higher in the H-IR group compared to GOG-99 eligible (34.6% vs 16.3%, p=0.0004, 28.3% vs. 10.6%, p=0.0002). CONCLUSIONS: Patients with H-IR disease based on uterine characteristics alone have substantial risk of nodal involvement. Knowledge of LN status may better define risk, prognosis, and postoperative treatment.

Implementation of a surgical handover tool in a busy tertiary referral centre: a complete audit cycle.

BACKGROUND: The implementation of the European work-time directive has created increased transitions of care during weekends as doctors adhere to a shift-work structure. This raises concerns over continuity of care and patient safety. To address this, doctors must develop a time efficient yet safe system of handover of patients to the team on-call. Intuitively weekend care provides the ideal setting to develop a handover tool. AIM: To develop and implement a process of surgical handover and to improve weekend discharge rate on a surgical service. METHODS: Data was collected at three time-points over a 6 months period (October 2013-March 2014) encompassing development, implementation, re-evaluation and modification of the handover process. The outcomes measured were: number of inpatients, number of weekend discharges, length of stay (LOS) of inpatients recorded for the four weekends within the month, and total emergency response team (ERT) calls each month. RESULTS: Mean number of included patients each month was 294 (σ = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p < 0.05). Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p < 0.05) and the total number of ERT calls for the month reduced from 12 to 4 (p < 0.05). CONCLUSIONS: The standardisation of weekend handover using a combination of an electronic tool supplemented with verbal handover is feasible. It resulted in a significant improvement in surrogate markers of patient care quality.

Protocol variations and six-minute walk test performance in stroke survivors: a systematic review with meta-analysis.

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke. Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.

Aortic atresia and aortico-left ventricular tunnel: successful surgical management by Konno aortoventriculoplasty in a neonate.

A newborn infant with aortic atresia and aortico-left ventricular tunnel was successfully treated by Konno aortoventriculoplasty. A 15 mm Ionescu-Shiley pericardial xenograft was inserted when the patient was 5 days old and it was replaced with a 19 mm St. Jude Medical prosthesis at 2 years of age.

Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy.

OBJECTIVE: To complete a systematic review of the published literature comparing complications, postoperative recovery time, and costs following laparoscopy-assisted vaginal hysterectomy, total abdominal hysterectomy (TAH), and vaginal hysterectomy. DATA SOURCES: We searched MEDLINE and several bibliographies, identifying all reports using the term "laparoscopy-assisted hysterectomy" published from 1989 to September 1995. METHODS OF STUDY SELECTION: We excluded case reports, letters, and reports of laparoscopy-assisted vaginal hysterectomy procedures used for radical cancer surgery, sex-change operations, total laparoscopic hysterectomy, or supracervical hysterectomy. TABULATION, INTEGRATION, AND RESULTS: Cases identified included 3112 laparoscopy-assisted vaginal hysterectomies, 1618 TAHs, and 690 vaginal hysterectomies. Laparoscopy-assisted vaginal hysterectomy cases compared with TAH cases demonstrated significantly greater incidence of bladder injury (1.8% for laparoscopy-assisted vaginal hysterectomy versus 0.4% for TAH; P = .01), significantly longer operating room time (115 minutes, standard deviation [SD] 37 minutes, for laparoscopy-assisted vaginal hysterectomy versus 87 minutes, SD 18 minutes, for TAH; P < .001), and significantly shorter hospitalization (49 hours, SD 16 hours, for laparoscopy-assisted vaginal hysterectomy versus 79 hours, SD 20 hours, for TAH; P < .001). Use of analgesia was consistently less for laparoscopy-assisted vaginal hysterectomy and return to full activity was always sooner when compared to TAH. Cost for the new procedure was higher in seven out of 11 studies, but when disposable instruments and hospital length of stay are considered, the remaining four studies reported a lower cost for laparoscopy-assisted vaginal hysterectomy. CONCLUSION: Although laparoscopy-assisted vaginal hysterectomy involves a shorter hospital stay, speedier postoperative recovery, and less analgesia use, there is also a higher rate of bladder injury and lengthier surgery. These outcomes must be weighed when choosing an intervention.

Vaccination of boars with a GnRH vaccine (Improvac) eliminates boar taint and increases growth performance.

Peri- and postpubertal boars accumulate substances (e.g., androstenone and skatole) in their fatty tissue that are responsible for boar taint in pork. The objective of this study was to assess the efficacy of a GnRH vaccine, Improvac, in eliminating boar taint. Three hundred male (200 intact boars, 100 barrows) crossbred (Large White x Landrace) pigs were used in a 2 x 3 factorially arranged experiment. The respective factors were sex group (barrows, boars treated with placebo, or boars treated with Improvac) and slaughter age (23 or 26 wk). Vaccines were administered 8 and 4 wk before slaughter. All Improvac-treated pigs exhibited anti-GnRH titers. Testes and bulbo-urethral gland weights in treated pigs were reduced by approximately 50% (P < 0.001) and serum testosterone levels were below 2 ng/mL in the majority of treated boars (94 and 92% across both age groups at 2 and 4 wk, respectively). Boar taint, as assessed by the concentration of androstenone and skatole in s.c. fat, was suppressed to low or undetectable levels in 100% of Improvac-treated boars. No Improvac-treated pigs had significant concentrations of either androstenone (> 1.0 microg/g) or skatole (> 0.20 microg/g). In contrast, 49.5% of placebo-treated controls had significant androstenone and 10.8% had significant skatole levels, resulting in 10% of the control boars with high concentrations of both compounds. The mean concentrations of taint compounds in the Improvac-treated pigs were not significantly different from those in barrows. Improvac-treated boars grew more rapidly (P = 0.051 and < 0.001 for pigs slaughtered at 23 and 26 wk of age, respectively) than control boars over the 4 wk after the secondary vaccination, possibly because of reduced sexual and aggressive activities. Compared with barrows, Improvac-treated boars were leaner and had superior feed conversion efficiency. The vaccine was well tolerated by the pigs, and no observable site reactions could be detected at the time of slaughter. Vaccination of boars with Improvac allows production of heavy boars with improved meat quality through prevention and control of boar taint.

Pharmacology of narcotic analgesics in the horse: selective blockade of narcotic-induced locomotor activity.

The locomotor responses of horses given morphine and fentanyl were blocked or lessened by administration of naloxone or acepromazine. Naloxone given at the dosage of 0.015 mg/kg completely blocked the locomotor activity induced in horses given fentanyl (0.020 mg/kg of body weight). The locomotor stimulation produced by morphine given at the dosage of 2.4 mg/kg was reduced by 75% of naloxone (0.020 mg/kg). Acepromazine partially blocked the locomotor responses to fentanyl and morphine. This blockade activity reached its peak about 30 minutes after acepromazine was given (IV) and lasted more than 6 hours. Simultaneous administration of acepromazine and morphine was associated with substantial respiratory depression for more than 4 hours after administration of both drugs. In other experiments, fentanyl did not add to the partial locomotor response observed after large doses of pentazocine were given--this being consistent with the concept that pentazocine possesses both antagonist and agonist actions at the narcotic receptor. Furosemide and phenylbutazone, given at usually used clinical doses, had no effect on the locomotor response to fentanyl, indicating that the usual clinical dosages of neither drug exerted stimulant or depressant actions.

Try to remember ... reminiscence as a nursing intervention.

1. For some, reminiscing is a beneficial coping strategy, helping to compensate for losses or self-care deficits they may be experiencing. 2. Implementation of this intervention in the cases presented here suggests that it is an effective way of promoting self-esteem and enhanced coping in some situations. 3. Nursing theories are potential frameworks for the use of reminiscence therapy as a nursing intervention or as a means of creating meaning with the person. 4. Future implications for practice lie in exploring the phenomenon of reminiscence within holistic nursing frameworks, such as Rogers' (1970) or Parse's (1992), enabling well-being and quality of life as a goal.

The surgical safety checklist survey: a national perspective on patient safety.

BACKGROUND: In 2008, the World Health Organisation (WHO) recommended practices to ensure the safety of patients worldwide. This led to the development of the Surgical Safety Checklist (SSC). Ireland has endorsed the SSC ( www.hiqa.ie/press-release/2008-06-17-health-information-and-quality-authority-launches-world-health-organization , 10). OBJECTIVES: We aimed to determine (i) whether SSC is being implemented, (ii) whether it promotes a safer surgical environment and (iii) identify problems associated with its introduction and on-going implementation. METHODS: All hospitals in Ireland with operating departments (n = 61) were invited to participate in an online survey. RESULTS: The response rate was 67 %. The WHO SSC or modified version is in place in 78 % (mean time: 20 months) of operating departments that responded. Partaking in Time Out as a team was reported as occurring in 57 % of cases. Greater than 60 % of respondents reported that the SSC was difficult to introduce and implement and that its introduction was time consuming. Further training in using the SSC was reported as desirable by 84 % of respondents. The introduction of the SSC was reported to be associated with an improvement in team communication (72 %), a positive change in team behaviour (63 %), an increase in the consistency of patient care (82 %) and a positive culture of safety in theatre (81 %). CONCLUSION: The SSC has not been implemented throughout all operating departments in Ireland. Where it has been introduced there has been a perceived positive change in safety culture. However, overall greater education, endorsement, teamwork, and communication will be required to optimise the potential benefits associated with this safety instrument. In order to properly determine the benefit of the SSC following its implementation, a formal audit of morbidity and mortality is required.

Viral hepatitis: enzyme assays and serologic procedures in the study of an epidemic.

An epidemic of viral hepatitis beginning in late 1975 in a residence for multiply handicapped children, recognized very early in its course, was investigated prospectively to permit comparison of enzymatic and serologic tests. Thirty-three residents of the institution and 46 full- and part-time employees were studied by the immune adherence hemagglutination procedure for antibody (anti-HAV) to hepatitis A virus (HAV). Of these, 31 residents and 37 staff members were susceptible at the beginning of the epidemic. Nineteen and six, respectively, had anti-HAV seroconversion indicating HAV infection. Thus, 12 children (39%) and 31 staff members (81%) of presumed susceptibles did not have serologic evidence of infection. The subclinical/clinical ratio for the children was 1.1:1; for personnel, it was 1:1. Serum alanine aminotransferase (ALT) levels compatible with viral hepatitis occurred in 21 persons (84%) who had anti-HAV seroconversion; conversely, there were 10 persons who had ALT abnormality without detectable anti-HAV in late specimens among the total of 68 susceptibles. There was no evidence the latter could be attributed to hepatitis B virus infection; therefore, they may represent the endemic occurrence of non-A, non-B agent(s).

Spectrum of sinus node dysfunction in two siblings.

Two siblings, ages 14 and 23, with various features of sinus node dysfunction have been reported. Sinus bradycardia was the presenting feature in both patients. During the follow-up period both patients developed various types of ectopic rhythms which increased with exercise. One of them developed "silent atrium" at the age of 23 and had cerebral embolus as a complication. The other patient had frequent syncopal episodes and had to be treated with a combination of electronic pacemaker and antiarrhythmic drugs.